Healthcare Provider Details

I. General information

NPI: 1740242841
Provider Name (Legal Business Name): ROGER STANLEY KILBOURN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 09/04/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WHITE EARTH INDIAN HEALTH CENTER 40520 COUNTY HIGHWAY 34
OGEMA MN
56569-9612
US

IV. Provider business mailing address

40520 COUNTY HIGHWAY 34
OGEMA MN
56569-9612
US

V. Phone/Fax

Practice location:
  • Phone: 218-983-4300
  • Fax: 218-983-6217
Mailing address:
  • Phone: 218-983-4300
  • Fax: 218-983-6217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO177082
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101014954
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: